MANIILAQ ASSOCIATION

11/24

Title: Chronic Disease Case Manager                                                                            Range:   15/16

Program:  Outpatient Services                                                                                     Status:   Non-Exempt                              
Housing Priority: 3                                                                                                      Covered:  Yes

POSITION SUMMARY

The Chronic Disease Case Manager (CDCM) will promote health care delivery across the continuum that will enhance the client’s quality of life, decrease fragmentation of care, while efficiently utilizing resources and containing cost. They will provide resource support to the Case Management Team. The CDCM will use a process that includes screening and case finding, comprehensive multidimensional assessment, care/discharge planning, connection with available resources, implementation of the plan, and on going monitoring and re-assessment. The plan sets goals and periods for achieved goals that are appropriate to the individual and their family and are agreed upon by the family and the treatment team. This position reports directly to the Outpatient Services Manager.

PRINCIPAL DUTIES AND RESPONSIBILITIES

1. Works in coordination with the Outpatient Services Manager to develop, implement, and maintain the Case Management Program according to the program goals and objectives.
2. Identifies, develops and maintains a current resource database of federal, state, community, and institutional resources.
3. Attends team conferences and networks for relationship building and resource development.
4. Using the Nursing Process develops, implements, monitors and modifies a plan of care for and with the individual and family/caregiver consistent with cultural, social, and psychological requirements, through an interdisciplinary, collaborative team approach.
5. Understands the developmental needs of all ages of patients throughout the continuum of life. Is able to adjust care to those needs. Documentation reflects that understanding.
6. Monitors the clients’ progress toward goal achievement with periodic reassessments of changes in health status.
7. Provides tracking and follow-up of abnormal test results in collaboration with provider team concept.
8. Supports and participates in teaching and training to expand services and increase public awareness of chronic disease prevention and control.
9. Develops standards, policies, procedures, and protocols to support nursing case management practice.
10. Helps to maintain referrals to individual Specialty Clinics, including scheduling and assisting doctors with procedures during scheduled clinic hours.
11. Assists in the coordination of patient appointments in Anchorage and the implementation, maintenance and follow-up in coordination with MHC Providers.
12. Assures labs have been drawn as scheduled and assists in the coordination of medication reconciliation with the Primary Care Provider, the Specialty Clinic, and/or ANMC.
13. Establishes, participates in, and evaluates program improvement goals such as patient outcomes, cost savings, patient compliance, and return to productivity.
14. Coordinates and facilitates health promotion, illness and disability prevention, and health education activities.
15. Participates in daily huddles in outpatient with the appropriate team members to include Providers, nurses, and unlicensed support staff.
16. Provides appropriate communication with others on the team as the need arises.
17. Maintains professional ethical standards of conduct at all times.
18. Demonstrates a positive customer service attitude at all times.
19. Utilizes team building, problem solving skills, and lean principles, in the on-going quality improvement initiatives.

MINIMUM QUALIFICATIONS

Graduated from and accredited RN or LPN Program with at least three years of experience. Must have an LPN/RN license in good standing. Must have at least two years Med/Surg experience and additional Case Management experience preferred. Must be able to pass the core competencies assigned to this position and maintain the educational requirements of the department.

DISCLAIMER

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job.  They are not intended to be considered an exhaustive list of all responsibilities, duties and skills required of personnel in this job, and the employer reserves the right to revise or change this description.  This description does not constitute a written or implied contract of employment.  To perform this job successfully, an individual must be able to satisfactorily perform each of the above essential duties and meet physical demands.  Reasonable accommodations may be made to enable individuals with disabilities to meet those conditions.